Ethan Stobaugh
Individual provider Active NPI Pharmacist · Horn Lake, MS
NPI 1326686254 · NPPES record last updated Dec 10, 2019
Key facts
- NPI
- 1326686254
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- E-14458 (MS)
- Practice address
- 3926 Goodman Rd W
Horn Lake, MS 38637-1324 - Phone
- (662) 393-7868
- NPI assigned
- Dec 10, 2019
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| E-14458 | MS | MD | Pharmacist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | E-14458 | MS | Yes |
Addresses
Primary practice location
3926 Goodman Rd W
Horn Lake, MS 38637-1324
Mailing address
3926 Goodman Rd W
Horn Lake, MS 38637-1324
Phone (662) 393-7868
Other providers in Horn Lake, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 10, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.